Physical Exam Write-up (Normal Findings) Flashcards
What are the general components of the physical exam write-up with all normal findings?
- General Appearance
- Vitals
- HEENT
- Neck
- Breasts
- Thorax and Back
- Lungs
- Heart
- Abdomen
- Extremities
- Lymph nodes
- Neurologic
(13. Gynecologic)
What are the components of the general appearance write-up?
- Age
- Gender
- Mental status (awake and alert)
- Appearance (healthy, looks stated age)
What are the components of the vitals write-up?
- Temperature (# degrees + method - oral, rectal, etc.)
- Blood pressure (Arm/Method)
- Heart rate
- Respiration rate
What are the broad components of the HEENT write-up?
- Head
- Eyes
- Ears
- Nose
- Throat and Mouth
What are the components of the Head write-up?
- Configuration (normocephalic)
- Hair (normal texture)
- Scalp (no lesions, tenderness)
What are the components of the Eye write-up?
- Sclera (white)
- Conjunctiva (pink)
- Fundoscopy:
a. Red reflex (present)
b. Disc (round, sharp margins, normal color)
c. Vessels (normal caliber, A/V ratio ~1/2)
d. Background (no abnormal pigmentation, hemorrhage, or exudate)
e. Macular (visualized)
What are the components of the Ear write-up?
- External ear (no lesions, masses, tenderness)
- Auditory canal (nomral)
- Eardrum (tympanic membrane is gray, translucent, with a normal light reflex)
What are the components of the Nose write-up?
- Color (pink, no discharge)
- Septum (midline)
- Inferior and middle turbinates (normal)
What are the components of the Throat and Mouth write-up?
- Teeth (present and in good dentition)
- Tongue (no lesions)
- Gums and mucosa (no swelling, bleeding, infection)
- Pharynx and tonsillar fossa (normal)
- Opening’s of Stensen’s and Wharton’s ducts (identified)
What are the components of the Neck write-up?
- Active ROM (normal flexion, extension, lateral rotations, tilting)
- Trachea (midline, mobile)
- Thyroid (non-palpable or palpable, normal size and consistency, no lesions)
- Suprasternal notch (no pulsation)
What are the components of the Breast write-up?
- Inspection (normal size, symmetrical, nipples are symmetircal and everted)
- Palpation (no masses, no nipple discharge)
What are the components of the Thorax and Back write-up?
- Observation (symmetrical expansion with respiration)
2. Percussion (no spinal or CVA tenderness)
What are the components of the Lung write-up?
- Percussion and palpation of lung fields: (normal resonance to percussion)
- Auscultation (clear, normal vesicular breath sounds)
What are the broad components of the Heart write-up?
- Neck Veins (no JVD at 45 degrees)
- Carotid Arteries
- Precordium
What are the components of the Carotid Artery write-up?
- Palpation (normal upstroke and amplitude bilaterally)
2. Auscultation (no bruits)
What are the components of the Precordium write-up?
- Inspection (no lifts or heaves, PMI not visible)
- Palpation (no parasternal impulses, no thrills, PMI palpable in 5th ICS, MCL, normal size)
- Auscultation:
a. S1 (heard best at apex, normal intensity)
b. S2 (heard best at base, normal splitting, A2 > P2)
c. Extra sounds (no S3, S4)
d. Murmurs (no murmurs)
What are the broad components of the Abdomen exam?
- Observation (scaphoid, no scars or striae)
- Auscultation (normal bowel sounds, no bruits)
- Palpation (no tenderness, masses, guarding - superficial and deep)
- Liver
- Spleen (non-palpable)
- Kidneys (non-palpable)
- Femoral pulses
What are the components of the Liver write-up?
- Palpation (liver edge not palpable)
2. Percussion (~10 cm in R midclavicular line)
What are the components of the Femoral Pulses write-up?
- Palpation (2+, normal and symmetric)
2. Auscultation (no bruits)
What are the components of the Upper Extremities write-up?
- Nails (no cyanosis, clubbing)
- Palms (normal color, texture)
- Muscles (normal size)
- Joints:
a. Interphalangeal (normal ROM, no deformities)
b. Wrists
c. Elbows
d. Radial pulse (2+, normal and symmetric)
What are the components of the Lower Extremities write-up?
- Nails (no cyanosis, clubbing)
- Muscles (normal size)
- Joints:
a. Ankle
b. Knee
c. Hip - Pulses
a. Posterior tibial (2+ bilateral equal)
b. Dorsalis pedis (2+ bilateral equal)
What are the components of the Skin write-up?
Normal, no lesions
What are the components of the Lymph Nodes write-up?
- Neck:
a. Submental
b. Submandibular
c. Anterior and Posterior Cervical
d. Pre and Post Auricular
e. Suboccipital
f. Supraclavicular - Axillary
a. Central axillary
b. Pectoral
c. Subscapular
d. Lateral axillary - Epitrochlear
- Superficial inguinal (horizontal and vertical)
All not palpable
What are the broad components of the Neurologic write-up?
- Mental status (awake and alert, oriented to person, place, and time)
- Cranial Nerves
- Motor system
- Sensory
- Reflexes
- Coordination
What are the components of the CN write-up?
II: Visual acuity - 20/20 with pocket screener, both eyes
Visual fields - intact in all fields
II and III: pupillary reaction light - direct and consensual normal, accommodation - normal (PERRLA - pupils, equal, round, reactive to light, accommodation for both)
III, IV, VI: EOM - intact
V: light touch face- normal in all three divisions of V
VII: wrinkle forehead, close eyes, show teeth (normal)
VIII: hearing - normal by rough testing
X: couch - normal
XI: shrug shoulders and check SCM - normal
XII: protrude tongue - midline protrusion
What are the components of the motor system write-up?
- Normal tone
2. 5/5 strength in all extremities
What are the components of the sensory system write-up?
- Light touch - normal
- Position sense - normal
- Vibration - normal
- Sharp - normal
What are the components of the reflex write-up?
- Biceps (C5-6) 2/4
- Triceps (C6-7) 2/4
- Brachioradialis 2/4
- Knee (L2-4) 2/4
- Ankle (S1) 2/4
- Pathological - plantar reflex - none (bilateral)
What are the components of the coordination write-up?
- Gait and balance - normal
- Finger to nose - normal
- Rapid finger movements - normal
- Tandem walking - normal
- Rombert - negative
What’s on the differential for palpitations?
Cardiac
- Heart attack
- Arrhythmia (HOCM, heart disease)
- Valvular regurgitation
- Myo-/pericarditis
- Exercise-associated
- Anemia
Endocrine
- Thyrotoxicosis
- Electrolyte abnormalities
Psychiatric
1. Anxiety/panic attack
Other
- Medications
- Illicit drugs
- Nicotine
- Caffeine
- Musculoskeletal
- GERD